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The study examines the prevalence of depressive syndromes among unselected primary care attenders, as well as doctors' recognition and treatment rates, in order to examine patient and doctor-related factors associated with poor recognition. This nationwide study included a total of 20421 patients (aged 15-99 years) attending their primary care doctors (n = 633) on the study's target day in April 1999. Patients received a self-report questionnaire, including the Depression Screening Questionnaire (DSQ), to provide diagnoses of depressive disorders according to the criteria of DSM-IV and ICD-10. Doctors completed: (1) a pre-study questionnaire assessing data on doctors' psychosocial, professional and training background, as well as current practices in patients with depression and (2) an evaluation form for each patient seen to assess his diagnostic decision, clinical severity and treatment choices. Taking the DSQ as a yardstick, 4.2% of all primary care attenders fulfilled criteria for a major depressive episode according to DSM-IV; considerably higher rates of 11.3% were obtained using the ICD-10 criteria for mild depressive episodes. Rates of depression were higher in females, increased by age, and were also elevated in those retired, unemployed as well as non-working housemen/wives. Taking the doctors' decision of definite or probable depression, 75% of all DSM and 59% of all ICD-10 diagnoses were recognized by the treating physician. However, doctors also assigned diagnoses of definite depression in an additional 11.7% of patients not meeting either ICD-10 nor DSM-IV criteria. Among correctly identified depression cases doctors decided to prescribe drug treatments in 72.7% (DSM) and 60.8% (ICD). Some 16.2% of DSM and 10.1% of ICD-cases were referred to mental health specialists; non-drug interventions were prescribed for 19.8% (DSM) and 24.9% (ICD), respectively. Multiple logistic regression analyses revealed that recognition is associated with prior treatment episodes, increasing number of depression symptoms, patients higher age, practice experience of treating physician greater 5 years and psychomotor retardation. These findings confirm the high prevalence of depressive syndromes in primary care settings and underline the particular challenge posed by a high proportion of with near-threshold symptomology patients. Although recognition rates among more severe major depressive patients as well as treatments prescribed appear to be more favourable than in previous studies, the situation in less severe cases, and the high proportion of doctors' definite depression diagnoses in patients with depression symptoms that are clearly below even the subthreshold level, raises significant concerns.

Lignocaine is widely used as a local anaesthetic and antiarrhythmic drug. It is commonly administered to patients with acute myocardial infarction as prophylaxis for ventricular fibrillation, although its efficacy in preventing primary ventricular fibrillation is still debated. Toxicity, sometimes with serious clinical consequence, is not uncommom and is usually related to overdosage. Blood lignocaine concentrations correlate roughly with antiarrhythmic and toxic effects and might be useful as an end point for monitoring prophylactic therapy. Administration of lignocaine as a local anaesthetic may result in blood lignocaine concentration in the antiarrhythmic or even toxic ranges. Expected peak levels for various routes of local anaesthesia are tabulated so that 'safe' total doses can be calculated. Intramuscular injection of high doses results in sustained therapeutic levels but is often associated with early minor toxicity. Lignocaine is eliminated primarily by hepatic metabolism, which appears to be limited by liver perfusion. Active metabolites may contribute to therapeutic and/or toxic effects. Disease states such as cardiac failure or drugs that alter hepatic blood flow may significantly affect lignocaine clearance. Pharmacokinetic studies in man show wide variability in drug disposition between patients, even when cardiac and hepatic status is considered, making specific dosing recommendations a problem. With intravenous injection, multicompartment kinetics is observed, with an initial rapid decline phase and initial decline in antiarrhythmic activity due to redistribution. With constant infusion, steady state concentrations of lignocaine are seen after 3 to 4 hours in normal subjects and after 8 to 10 hours in patients with myocardial infarction without circulatory insufficiency. In patients with cardiac failure, blood lignocaine concentration may continue to rise for 24 to 48 hours. In the presence of cardiac failure, decreased volumes of distribution and clearance require reduction in loading and maintenance doses. Lignocaine clearance is reduced in patients with liver disease and appears to be a sensitive index of liver dysfunction. A dosing algorithm for treatment of patients with myocardial infarction is presented.

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